The ABCs of veterinary dentistry: K is for kick starting your dental practice

Nearly eight of 10 of the dogs and cats you see daily need dental care, yet a much smaller percentage receive it. How can you kick start dentistry as a domain within your practice and realize the good that it provides for your patients, their owners and your practice?

1. Believe in dentistry

2. Invest in the best education, materials and equipment

3. Perform a great exam

4. Prevent the preventable and treat the treatable.

1. Believe in dentistry

Not everyone likes running, biking or lifting weights, but we all believe it's good for us. The same is true of dentistry-you don't have to like or even love it. All that's required to move forward is to believe in its benefits. The long-term benefit of periodontal care and after care is relieving inflammation. Human dentists are convinced that much damage to our bodies arises from periodontal disease inflammation, why should it be different for companion animals?

We have all seen older dogs and cats with fractured teeth and advanced periodontal diseases that appear to be eating well and thriving. Do these patients really need immediate dental care? Yes, they really need it. Dogs and cats have similar oral pain pathways as people. Dental disease hurts-even if it's chronic persistent dull pain. Imagine if you walked around with inflamed bleeding gums or if it hurt every time you chewed on one side.

No animal should be left to silently suffer. Proactive dental care and home preventive measures to prevent recurrence can eliminate the discomfort (Figures 1A and 1B). Rejoice in the smiles on your clients' faces exclaiming they have a “new” dog or cat after comprehensive dental examination and care for pathology discovered.

Figure 1A. Multiple crown fractures without apparent pulp exposure affecting a dog's right mandibular first molar. (All figures courtesy of Dr. Jan Bellows, unless otherwise indicated.)

Figure 1B. An intraoral radiograph reveals periapical lysis consistent with painful advanced endodontic disease. Root canal therapy or extraction is indicated to relieve discomfort.

2. Invest in dental education, the best materials and dental equipment

There is no greater rate of return in your veterinary practice then dentistry. To do it right you need to know how to diagnose, treat (or refer) dental pathology you see and have the best equipment and materials to do the job right.

Education. Most veterinarians receive only minutes or a few hours of dental training during veterinary school. But all is not lost. Great resources abound for teaching what we missed. Examples of dental continuing education opportunities include lectures and hands-on wet labs at local and national meetings, VIN's online dental classes and the Veterinary Dental Forum (Nashville, Sept. 14-17, 2017; Phoenix, Nov. 15-18, 2018; Orlando, Sept. 26-29, 2019). Our next local hands-on dental wet lab in Weston, Florida, for veterinarians and technicians is Oct. 15, 2017. For additional information, please contact me at dentalvet@aol.com.

Tackling dental education as a whole can be daunting. Spending time understanding each of the subspecialties (intraoral radiology, periodontal diseases, oral surgery, oral medicine, endodontics, orthodontics, and oral trauma)-cutting “dentistry” into bite-sized pieces-becomes doable for those who are committed. Time spent practicing hands-on intraoral radiology and periodontal wet labs pays off many times over (Figure 2).

Figure 2. A local dentistry wet lab for veterinarians and technicians.Dental training needs to be shared with the entire staff, including your receptionists. They need to understand what you are doing to help patients during the comprehensive oral prevention, assessment, and treatment (COPAT) visit and how to schedule appointments, including preparing your client for two steps: 1) oral diagnosis and teeth cleaning followed by 2) care for pathology uncovered. When asked, receptionists can quote fees for the first step (diagnostics and dental scaling) but not the second step until an anesthetized tooth-by-tooth examination has been performed. Treatment can be completed during the same anesthetic period or during a later appointment.

Much of dentistry is technician-run. Your dental assistants need to be able to expose and collate full-mouth intraoral images within 15 minutes. They also need to know how to completely chart the oral cavity, clean and polish the teeth and apply local antimicrobials and sealants. All of this will take training which is available at national veterinary meetings, on VIN, and often locally.

Kick starting your dental practice should not include performing advanced dentistry (endodontics, orthodontics, complicated oral surgery), which are taught during three-year dental residencies. You can do enough good focusing on prevention, diagnosis and treatment of periodontal diseases and referring advanced dental care.

Becoming friendly with your local veterinary dentist is another great way to learn by observing, especially by accompanying the patients you refer. Veterinary dentists (avdc.org) welcome the opportunity to share and teach colleagues.

Materials and equipment. To perform even basic quality dentistry, a lot of equipment and materials are necessary.

Examination essentials:

• Periodontal probe

• Explorer

• Intraoral dental radiography

• Dental charts

Treatment essentials:

• Ultrasonic scaler

• Polishing equipment

• Curettes

• Regional anesthesia

• High-/low-speed handpieces, burs and delivery systems

• Wing-tipped elevators

• Periotomes

• Extraction forceps

• 4-0, 5-0 suture material on P-3 reverse cutting needles

• Staff safety equipment (eye goggles, face mask, ear protection)

• Dental sealants (SANOS-AllAccem, OraVet-Merial)

• Locally applied antimicrobials (Clindoral-Trilogic Pharm, Doxirobe-Zoetis).

After care essentials:

• Veterinary Oral Health Council (VOHC.org) products including daily chews, water additives, dentifrice and diets.

3. Perform a great exam

Clinical exam. Do not allow “dental drop-offs” for dogs and cats with halitosis. Each patient needs a clinical examination with the client present to take a look inside the mouth and review the oral assessment, treatment and prevention (oral ATP) process. Often without a clinical examination the client does not understand that “a dental” is much more that cleaning teeth. If the client can not arrange to be at the appointment the same day as the procedure, arrange an in-person exam the week before.

Anesthetized exam. What is observed clinically, during probing, and with the help of intraoral radiography during the dental examination in an anesthetized patient is the foundation of dental diagnostics. Dogs normally have 42 “tooth patients” in their mouths, while cats have 30. Some of the “patients” will be in good shape and not need additional care, while others will be quite ill. When clients present their companion animals for dental care complaining of halitosis or gingival inflammation, additional care in addition to dental scaling and polishing is needed.

Dental probing around each tooth and between tooth roots is most important. When deep pockets are present (Figures 3A-3C), locally applied antimicrobials, gingival surgery or extraction is needed.

Figure 3A. A periodontal probe confirming a deep pocket between the maxillary fourth premolar and first molar.

Figure 3B. An 8-mm pocket discovered on the palatal aspect of a rotated maxillary third premolar; extraction is indicated.

Figure 3C. A 3-mm probing depth between the roots of left maxillary first molar.

If bleeding occurs during probing, application of a local antimicrobial coupled with stringent home care will usually resolve the bleeding and prevent progression of periodontal disease (Figures 4A-4D).

Figure 4A. Bleeding on probing.

Figure 4B. Drying the sulcus with compressed air.

Figure 4C. Application of a local antimicrobial.

Figure 4D. Completed application of the local antimicrobial.

Fractured teeth are commonly observed during the anesthetized examination. Pulp exposure can either be confirmed visually or with the aid of a dental explorer (Figure 5). If there is pulp exposure, root canal therapy or extraction is indicated.

Figure 5. A shepherd's hook explorer used to probe a crown root fractured maxillary premolar. The explorer tip stuck into the dentin, confirming pulp exposure.

Intraoral radiography-A MUST. Remember, approximately 60 percent of the tooth is located subgingivally. The radiographs allow you to “see” below the gum line. Full-mouth radiographs should be exposed and examined on every professional oral hygiene visit. Figuring out how to accomplish this can be a challenge both in staff time and client compliance. Some practices choose not to charge for the radiographs separately. Other practices charge what they think is reasonable without giving the owner an option of radiographs or not.

Studies have found that in those cases without clinical findings, radiographs showed clinically important pathology in 27.8% of dogs and 41.7% of cats.1 These are lesions that cannot be seen or probed on an anesthetized examination (Figures 6A, 6B, 7A and 7B). In animals with identifiable pathology on examination, radiographs showed other undetected pathology in approximately 50% of cases.

Figure 6A. Left mandibular canine first and second premolars with plaque and tartar.

Figure 6B. An intraoral radiograph revealing stages 3 and 4 periodontal disease; extraction of the imaged premolars is indicated.

Figure 7A. Gingival inflammation surrounding the right mandibular molar in a cat.

Figure 7B. A radiograph confirming bone loss consistent with advanced periodontal disease, extraction indicated.

Charting. If a thorough examination is the foundation for veterinary dentistry, charting documents pathology and helps create a tooth-by-tooth treatment plan. Abnormal examination findings are noted on the chart, which becomes a “to do” list to discuss with the pet owner either briefly while the animal is anesthetized or at the time of release to schedule a near future treatment appointment (Figures 8A-8C).

Figure 8A. An electronic dental chart completed chair side. (Image courtesy of vetdentalcharts.com.)

Figure 8B. Examination findings.

Figure 8C. Treatment performed.

Every professional oral hygiene visit should be clinically imaged and memorialized in a go home report. These printouts serve as information and publicity sheets that clients share with others to commend your dental acumen. Most clients save them forever.

4. Prevent the preventable; treat the treatable

“Dentistry” is more than cleaning teeth and extracting those with advanced periodontal disease. Your dental practice's goals should be to prevent oral disease and to restore your patient's mouths to as pristine condition as possible during the professional oral hygiene visit. Each tooth needs a decision based on examination findings to do one of the following:

1. Leave the tooth untreated because other than cleaning it does not need further care.

2. Note on the record to follow uncovered pathology at future visits because the mouth is functional and nonpainful or the client is not willing at this time to proceed with needed care.

3. Extract the tooth (teeth).

4. Refer for advanced dental care.

Actively advising how to prevent or decrease the progression of dental disease is imperative to your dental practice. Recognizing and treating dental disease is only two-thirds of a dental practice. Prevention is the remaining third and needs to be promoted to first place-prevention first! Fortunately, the VOHC (VOHC.org) provides us with a list of evidence-based products, which can help decrease the progression of plaque and/or tartar. Encouraging frequent (monthly) oral hygiene rechecks allows you to follow your patient's dental hygiene and make recommendations if needed on how to improve plaque and tartar control. In our practice we do not charge for those follow up visits. Those clients who comply with daily home care really appreciate your commitment to keeping their pets' mouths healthy, translating into longer happier lives.

Getting 'r done

Kick starting your dental practice is so worth it-everyone wins. How to get from here to there? Choose a staff member who is into dentistry and let him or her carry the torch. The goal is not to do more dentals. Instead the aim is to thoroughly diagnose and treat every case on the table, then follow with a tailored prevention program. You can do it.

Reference

1. Verstraete FJ, Kass PH, Terpak CH. Diagnostic value of full-mouth radiography in dogs. Am J Vet Res 1998;59(6):686-691.